Principles of Therapy

Specific therapy tailored to the identified etiology or underlying disorder is indicated

Choice of therapeutic agent is based on patient’s medical history (prior efficacy or side effects, contraindications), concomitant diseases (preferring Aspirin when it is already used as antiplatelet therapy) and physician’s knowledge and skills

Pharmacotherapy

Aspirin and Nonsteroidal Anti-inflammatory Drugs (NSAIDs)

First-line agents for acute pericarditis

Aspirin is the preferred agent for patients with pericarditis following myocardial infarction

Commonly used NSAIDs include Ibuprofen and Indomethacin

Given for 1-2 weeks then tapered until symptoms resolve and serum inflammatory markers improve (consider serum CRP levels in guiding duration of treatment and evaluating efficacy of therapy)

2-4 weeks for recurrent pericarditis

Gastroprotection should be considered due to the high doses required

Suspect a cause other than postviral or idiopathic if symptoms (eg fever or chest discomfort) persist >1 week or a larger or new pericardial effusion develops during treatment

Use is off-label

Colchicine

Used as an adjunct to Aspirin and NSAID therapy

Helps reduce the rate of recurrence

Duration of therapy is up to 3 months

Up to 6 months for recurrent pericarditis

Well tolerated when given long-term at a low dose

Uncommon side effects include hepatic toxicity and myelosuppression

Reduce dose in patients with advanced renal dysfunction or those receiving concurrent therapy with P-glycoprotein inhibitors or moderate to strong CYP3A4 inhibitors

Use is off-label

Glucocorticoids

Given to patients who are intolerant of, refractory to, or have contraindications to Aspirin or NSAIDs and Colchicine

Also considered when a specific indication, eg autoimmune disease, is present or an infectious etiology has been excluded

Not used as primary therapy in patients with acute pericarditis due to high rate of relapse

Given at a low dose for 2 weeks then tapered slowly; 2-4 weeks for recurrent pericarditis

In the setting of incomplete response to Aspirin or NSAIDs and Colchicine in patients with recurrent pericarditis, triple therapy with low to moderate-dose steroids added to Aspirin or NSAIDs and Colchicine is given (not to be used as a substitute for these drugs) then tapered with a single drug class at a time before Colchicine is slowly discontinued

Slow tapering and a prolonged course of steroid therapy may be required though with potential for steroid-associated side effects and risk of additional recurrences; consider measures for osteoporosis prevention

HIV-negative cases of TB pericarditis may be given adjunctive steroids

If with cardiac tamponade, pericardiocentesis may be performed

Constrictive Pericarditis

Can occur after any pericardial disease but rarely develops after recurrent pericarditis

Risk is low (1%) in patients with viral and idiopathic pericarditis, intermediate (2-5%) for neoplastic, autoimmune and immune-mediated etiologies, and high (20-30%) for bacterial causes, eg TB and purulent pericarditis

It is recommended to medically treat specific conditions (eg tuberculous pericarditis) to avoid progression of constriction and to control symptoms of congestion

Effusive-constrictive pericarditis may be treated with pericardiocentesis, chronic permanent constriction with pericardiectomy

Drug-related Acute Pericarditis and Pericardial Effusion

Damage to the pericardium is associated with “serum sickness” brought about by blood products, direct pericardial applications of talc or magnesium silicate, sclerosants, asbestos and iron in beta thalassemia

Anticoagulant therapies may cause hemorrhagic or worsening pericardial effusion that may lead to cardiac tamponade, though this is not supported by current available data

Management is stopping the causative agent and administering symptomatic treatment

Myopericarditis

It is pericarditis with concomitant myocardial inflammation but normal ventricular function

Most common causes are viral infections in developed countries while other infectious causes, eg TB, are common in developing countries

Management is similar to that of acute pericarditis: Exercise restriction, empiric Aspirin or NSAID therapy for chest pain and corticosteroids in cases of intolerance, contraindications or failure of Aspirin or NSAIDs

Data to recommend Colchicine use is insufficient

Purulent Pericarditis

Management is with surgical drainage of effusion and IV antibiotics

Dense adhesions and thick purulent effusions may require pericardiectomy for adequate drainage and prevention of constriction

Radiation Pericarditis

Acute pericarditis with or without effusion may develop following chest radiation

Management includes reduction in dose and volume of cardiac irradiation and pericardiectomy due to radiation-induced constrictive pericarditis